Helen Coogan
PFD Report
All Responded
Ref: 2023-0194
All 1 response received
· Deadline: 17 Aug 2023
Coroner's Concerns (AI summary)
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
View full coroner's concerns
You provided a statement regarding the care given to Ms Coogan by you and your colleagues at the Ritchie Street Group Practice. In it, you said that she reported to Dr in July 2022 that she had had abdominal cramps present for months, with alternating loose stool and constipation. You said that a qFIT tool test for blood was requested but there was no subsequent result. You said the same about the qFIT requested on 13 September 2022.
It was not clear to me why there were no qFIT results but, given the cause of Ms Coogan’s death, that seems to me to be a matter worthy of your investigation, particularly in case there is some system issue.
It was not clear to me why there were no qFIT results but, given the cause of Ms Coogan’s death, that seems to me to be a matter worthy of your investigation, particularly in case there is some system issue.
Responses
Noted
The practice discussed the case at a partners meeting and raised a significant event to discuss with the wider team, but concluded that no further action could be taken because the patient did not complete the advised tests. (AI summary)
The practice discussed the case at a partners meeting and raised a significant event to discuss with the wider team, but concluded that no further action could be taken because the patient did not complete the advised tests. (AI summary)
View full response
Dear Coroner
Re: Mrs Helen Coogan (D.O.B 21-Mar-1945 ) 21A Arundel Square London N7 8AS
Many thanks for your Prevention of Future Deaths report.
She first presented with bowel symptoms in July 2022. A qFIT test was organised then and in total organised 4 times between July and Sept 2022 when she had contact with someone and was noted to have not completed the test. I am unclear why she did not do it.
She did do 3 other stool tests in July 22 but none were for qFIT - she was subsequently advised of this and the need to do it but still didn’t.
She was reviewed by several GPs and during this period she was also assessed by our paramedic and the Whittington’s Rapid Response Team. She also attended A&E but took her own discharge before being assessed. The Rapid Response Team felt she had capacity.
Plan
- discussed it at a partners meeting – nil further could be added
- raised a significant event to discuss with the wider team to see if anything can learned and improved from this – nil further could be added.
I cannot see what else could have been done to get a patient do a test that was advised and organised several times. It is a test patients have to produce and collect a sample to be able to process.
Re: Mrs Helen Coogan (D.O.B 21-Mar-1945 ) 21A Arundel Square London N7 8AS
Many thanks for your Prevention of Future Deaths report.
She first presented with bowel symptoms in July 2022. A qFIT test was organised then and in total organised 4 times between July and Sept 2022 when she had contact with someone and was noted to have not completed the test. I am unclear why she did not do it.
She did do 3 other stool tests in July 22 but none were for qFIT - she was subsequently advised of this and the need to do it but still didn’t.
She was reviewed by several GPs and during this period she was also assessed by our paramedic and the Whittington’s Rapid Response Team. She also attended A&E but took her own discharge before being assessed. The Rapid Response Team felt she had capacity.
Plan
- discussed it at a partners meeting – nil further could be added
- raised a significant event to discuss with the wider team to see if anything can learned and improved from this – nil further could be added.
I cannot see what else could have been done to get a patient do a test that was advised and organised several times. It is a test patients have to produce and collect a sample to be able to process.
Sent To
- Ritchie Street Group Practice
Response Status
Linked responses
1 of 1
56-Day Deadline
17 Aug 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 27 October 2022, I commenced an investigation into the death of Helen Coogan aged 77 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest as follows.
“Helen Coogan died in October 2022 from a natural cause, being cancer. She first sought advice from her general practitioner regarding related symptoms in July 2022, but there was no result from the qFIT (faecal immunochemical test) ordered.”
“Helen Coogan died in October 2022 from a natural cause, being cancer. She first sought advice from her general practitioner regarding related symptoms in July 2022, but there was no result from the qFIT (faecal immunochemical test) ordered.”
Circumstances of the Death
The medical cause of death was: 1a sudden cardiac death 1b metastatic neuroendocrine carcinoma of the ileocaecal valve and coronary artery atheroma 2 chronic obstructive pulmonary disease, hypertension and atrial fibrillation
Copies Sent To
, children of Helen Coogan
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.